Provider Demographics
NPI:1760479539
Name:EDMONDS, JENNIFER C (CCC-A)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:EDMONDS
Suffix:
Gender:F
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19662
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9662
Mailing Address - Country:US
Mailing Address - Phone:217-545-6099
Mailing Address - Fax:217-545-0253
Practice Address - Street 1:301 N 8TH ST
Practice Address - Street 2:STE PAV 5B
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1041
Practice Address - Country:US
Practice Address - Phone:217-545-6099
Practice Address - Fax:217-545-0253
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001140237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
Q50334Medicare UPIN
IL$$$$$$$$$001Medicaid